Rate Of Sentinel Lymph Node Biopsy Research Articles

Sentinel Lymph Node Biopsy in Patients Who Have Negative Conversion of Axillary Lymph Node after Neoadjuvant Chemotherapy for Node Positive Breast Cancer.

Abstract Background: Sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NAC) has been currently debatable. It is possible that the tumor response to chemotherapy may alter the lymphatic drainage thus causing lower SLN identification rate and higher false negative rate. Further, the response of NAC can be different in each lymph nodes. It is doubtful whether SLNB can accurately predict axillary lymph node (ALN) status after NAC. The aim of this study to determine the identification rate, the false-negative rate, and the accuracy of SLNB after NAC for node positive breast cancer.Patients and Methods: A prospective study was initiated to evaluate the results of SLNB after NAC. From January 2007 to April 2009, 81 patients with positive axillary lymph nodes enrolled from two institutions after IRB-approved. They received NAC and then evaluated negative conversion of metastatic lymph node with both PET and breast US. All of them underwent ALN dissection after SLNB with subareolar intradermal injection technique using radioisotope. We evaluated the identification rate, false negative rate, accuracy of SLNB according to the response of chemotherapy in axillary lymph nodes (negative conversion group or remaining positive group).Results: Before the NAC, 31 patients had multiple axillary lymph node metastasis and 50 patients had single metastasis. After NAC 44 cases (54.3%) turned into negative node and 37 cases (45.7%) remained positive nodes. Total identification rate was 80.2% (65 of 81), false negative rate was 19.0% (8 of 42) and accuracy was 87.7% (57 of 65). In negative conversion group showed 84.1% (37 of 44) of identification rate, 21.1% (4 of 19) of false negative rate, 89.2% (33 of 37) of accuracy. In remaining positive group revealed 75.7% (28 of 37) of identification rate, 17.4% (4 of 23) of false negative rate, 85.7% (24/28) of accuracy. There was no statistical significant difference of identification rate, false negative rate, accuracy of SLNB among the two group after NAC (p=0.343, p=0.534, p=0.478, respectively).Conclusion: This study showed relatively low detection rate and accuracy, high false-negative rate of SLNB, even if the positive nodes changed to negative node after NAC. Thus sentinel lymph node biopsy after NAC for node positive breast cancer should be cautious. Since this study had small number of negative conversion patients, further larger prospective studies are required for more proper conclusion. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1022.

Who Is to Blame for False-Negative Sentinel Node Biopsies in Melanoma?

No matter how one defines standard of care, sentinel lymph node biopsy (SLNB) has become standard of care for the treatment of clinically localized melanoma.1,2 Given this fact, it is surprising that more attention has not been paid to the issue of false-negative results of sentinel node biopsy. In the current issue of Annals of Surgical Oncology, Scoggins et al. report on the false-negative rate of sentinel node biopsy from a large series of patients entered prospectively into the multi-institutional Sunbelt Melanoma Trial.3 An important starting point for any discussion of this topic is how to define and report the false-negative rate. Some investigators have reported the number of false-negative sentinel node biopsies (generally defined as any first recurrence of melanoma in a lymph node potentially draining the primary tumor) occurring out of all procedures performed. This is an incorrect representation of the false-negative rate and not a relevant number to patients and surgeons. In contrast, a very important number is the ratio of true-negative biopsies to all negative biopsies (false negatives plus true negatives). This is the negative predictive value of the sentinel node biopsy procedure and is of great value to surgeons when they counsel patients after a negative sentinel node biopsy procedure, but it is still not the false-negative rate. The negative predictive value of sentinel node biopsy in large series has been reported between 94 and 98.5% (Table 1), meaning that only 2–6 patients per 100 who are told their nodes are negative are given that information incorrectly. However, the actual definition of the false-negative rate is the ratio of false-negative results to the total number of positive lymph nodes (false negatives plus true positives). This value has been reported in the range 6–21%. Importantly, any method of reporting on the likelihood that a truly positive lymph node will be missed by the sentinel node procedure depends on the a priori likelihood that any lymph nodes are actually involved by melanoma. Put another way, if all the lymph nodes in a patient are uninvolved by tumor, it does not matter which nodes the surgeon removes—the result will be a true negative. The corollary of this, however, is that patients whose melanoma is most likely to have spread to the regional nodes are those most likely to have a false-negative sentinel node biopsy. It also follows that different series of patients undergoing sentinel node biopsy using identical techniques (and with identical accuracy) will report different false-negative rates and negative predictive values if the baseline characteristics of the melanoma patients differ. In addition, because nodal recurrences can take many years to manifest clinically, as the duration of follow-up increases, the false-negative rate and total positive node percentage will increase. In the Sunbelt Melanoma Trial data reported by Scoggins et al., after median follow-up of 61 months, the overall likelihood of a positive lymph node was 19.8% (486/2,451), the negative predictive value of a sentinel node biopsy was 97.0% (1,906/59 + 1,906), and the false-negative rate was 10.8% (59/59 + 486).3 The corresponding values in other contemporary large series of melanoma patients undergoing sentinel node biopsy are shown in Table 1.

Sentinel lymph node biopsy using CT lymphography in breast cancer

Sentinel lymph node biopsy (SLNB) is a standard surgical procedure for patients with early breast cancer. The combination of radioisotope (RI) and dye staining is the most accurate method for identification of sentinel lymph nodes (SLN). However, institutions without RI centers perform SLNB by blue dye alone. The identification rate with the dye method alone is inferior to the RI combination method. In our institution, the identification rate of SLNBs by the dye method alone was 95%. So we started this study of SLNB using computed tomographic lymphography (CTLG). Three hundred twenty-four patients with primary breast cancer and no clinical evidence of lymph node metastasis were studied. Identification of SLN was performed by CTLG and the dye-staining method. The identification rate of SLNs was analyzed for relation with the clinicopathological findings. The SLN identification rate was 98.5% with CTLG and 98.8% when combined with the dye-staining method. The identification rate with CTLG was significantly lower in the initial cases. CTLG identified the SLNs in all cases 6months after its induction. Multi-route multi-SLN patterns, in which SLNs were easily missed by the dye method, were detected in 9.6% of the patients. There was a significant difference in the SLN metastasis rates; partial enhancement of the SLN with CTLG had the consequence that the metastasis-positive rate was high. The SLN identification rate was improved by combining the dye-staining method and CTLG. CTLG has a superior spatial resolution activity for detecting SLNs precisely; making CTLG available for the prediction of metastases has been suggested. It is possible to perform SLNB with high accuracy by using CTLG in the institutions that do not have RI.

False Negative Rate of Sentinel Lymph Node Biopsy in Multicentric and Multifocal Breast Cancers May be Higher in Cases with Large Additive Tumor Burden

We aimed to evaluate the feasibility of sentinel lymph node biopsy (SLNB) in multicentric/ multifocal breast cancer. In this prospective study, 23 women with multicentric/multifocal breast cancer underwent SLNB at our institution from April 2002 to February 2006. Presence of preoperative axillary metastases was confirmed by FNA. Patients underwent sub-areolar radiopharmaceutical injection +/- isosulfan blue to perform SLNB, then completion ALND. The false-negative (FN) rate of SLNB was determined based upon final pathology. Twenty women with multicentric and three with multifocal invasive carcinoma were enrolled. The SLN identification rate was 100%. The overall FN rate of SLNB was 15% (95% CI 0.0466, 0.4281). Both cases with FN SLNB had multicentric disease, pathologic stage III breast cancer and a larger tumor burden compared with the study population. SLNB using sub-areolar injection is feasible for patients with multicentric/multifocal breast cancer yet may be associated with a higher FN rate in patients with large additive tumor burden.

Invasive melanoma of the face: Patterns of local and regional disease in 261 patients managed at a single institution

e20015 Background: The face is a common site of melanoma occurrence, and lesions in this location present specific management challenges. The purpose of this study was to examine outcomes associated with invasive melanoma of the face, with respect to local, regional and distant recurrence. Methods: Patients with invasive melanoma of the face managed from 1997–2008 were identified from a large population-based tumor registry and retrospectively reviewed. Details of lesion histopathology, initial management, sentinel node biopsy (SNB), and local, regional or distant recurrences were recorded. Results: 261 patients were reviewed, mean age 68 and median tumor thickness 0.87mm. Three patients (1.1%) had clinically involved nodes at presentation and underwent nodal dissection. Of 108 patients who were eligible for SNB (with tumor thickness >1mm, Clark level ≥IV or ulceration) this was performed in only 29 (27%). SNB was successfully identified in 28 (97%). No facial nerve injuries occurred. A mean of 1.5 nodes were removed; from parotid region in 24, cervical chain in 12, submandibular in 5, submental in 1 and retroauricular in 1. SNB was positive in 3 (11%) who subsequently underwent neck dissection/parotidectomy. Mean follow-up duration was 37 months. Local recurrence occurred in 13 (5%), in-transit recurrence in 4 (1.5%) and distant recurrence in 20 (7.7%). Regional nodal recurrence occurred in 10 (3.8%); after negative SNB in 1 (SNB failure rate 3.7%), after unsuccessful SNB in 1, following neck dissection for nodal disease at presentation in 1, and in 7 who did not undergo SNB (including 6 patients who were eligible). During the study period there were 60 deaths (crude mortality 23%); due to melanoma in 16, unrelated causes in 41, and indeterminate in 3. Conclusions: Facial melanoma is associated with low rates of regional recurrence despite a low rate of SNB for eligible lesions. Sentinel nodes were most commonly found in the parotid region and could be safely removed without nerve injury. Most regional recurrences occurred in patients eligible for SNB not undergoing this procedure. Due to the older age of patients with facial melanoma, most deaths occurring are from unrelated conditions, and distant metastatic disease was seen in only a small percentage of cases. No significant financial relationships to disclose.

The impact of preoperative magnetic resonance imaging on surgical planning for women with ductal carcinoma in situ.

Abstract Abstract #1163 Background: Ductal carcinoma in situ (DCIS) accounts for about 20% of all female breast cancers and is now diagnosed 10 times more frequently than prior to the use of increased screening mammography. Although magnetic resonance imaging (MRI) has proven to be a useful imaging modality for invasive cancer, its role and impact in preoperative surgical planning for DCIS is unclear. Our aim is to determine if women diagnosed with pure DCIS on core-biopsy who have preoperative MRI are more likely to undergo mastectomy and sentinel lymph node biopsy (SLNB). Methods: Retrospective survey of women diagnosed with pure DCIS on stereotactic core biopsy between 2000-2007 at an academic tertiary referral center. All women underwent definitive surgical treatment for DCIS. Patient characteristics, surgical planning and surgical outcomes were compared between patients who underwent preoperative MRI and those without MRI. Continuous variables among the two groups were compared using the t-test. Differences in dichotomous variables between groups were compared using the chi-square test. Significance was determined if p<0.05. Results: Of 137 women diagnosed with DCIS, 39 underwent preoperative MRI. Mean age, DCIS size and grade, and presence of invasive cancer on surgical specimen were compared between the two groups. The only significant difference between the two groups was younger mean age in the group with preoperative MRI (51 vs 59 yrs, p=0.001). On univariate analysis, mastectomy and SLNB were more commonly employed in the MRI group. The mastectomy rate was 55% for women who had preoperative MRI and 17% for those who did not (p<0.0001). The SLNB rate was 46% for women had preoperative MRI and 23% for those who did not (p=0.009). Number of re-excisions, margin status and size were compared between the two groups. Preoperative MRI was not significantly associated with wider surgical margins or higher proportion of patients with negative margins. However, the mean number of re-excisions was lower in women who underwent preoperative MRI (0.7 vs. 1.2, p=0.003). The only independent factor associated with likelihood of preoperative MRI in the setting of DCIS was patient age. On multivariate analysis, use of SLNB was independently associated with mastectomy, DCIS size and DCIS grade (p=0.0001, p=0.011, p=0.024, respectively). In contrast, independent predictors of mastectomy were DCIS size and use of MRI (OR 5.1, 95% CI 2.0-13.2)). Conclusion: Women who underwent preoperative MRI for DCIS were younger and more likely to undergo mastectomy. However, women who had preoperative MRI required a lower number of re-excisions to obtain negative margins. Our study cannot address whether the strong association between preoperative MRI and mastectomy is a causal one. Nevertheless our data support a critical need for future studies to further define the benefit as well as consequences of the use of MRI for DCIS evaluation and treatment. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1163.

Subareolar injection may not always identify the same sentinel lymph nodes as peritumoral injection in breast cancer.

Abstract Abstract #1022 Background. Sentinel lymph node (SLN) biopsy is widely accepted as a standard surgical procedure for early breast cancer, but the optimal site for injection of mapping tracers is still controversial. We evaluated whether a combination of peritumoral injection and subareolar injection can improve the identification rate of SLN biopsy and decrease the false-negative rate.
 Methods. From August 2006 to April 2008, 155 patients with biopsy-proven operable breast cancer underwent SLN biopsy with peritumoral injection of radioisotope (Tc-99m-phytate) and subareolar injection of blue dye (patent blue dye).
 Results. The overall identification rate for blue and/or radioactive (hot) lymph nodes was 99.4% (154/155); the identification rate of blue-dyed lymph nodes was 98.1% (152/155) and of hot lymph nodes was 96.8% (150/155). A total number of the excised SLNs were 379 in these 154 patients, and the average number of SLNs in each patient was 2.4 (range, 1-9). The average number of SLNs was 2.0 (range, 1-8) for blue dye and 1.9 (range, 1-6) for radioactive (hot). Two hundred twenty-six nodes (59.6%) were blue and hot, while 79 were blue-only and 74 were hot-only. Consequently, no concordance between the hot node and the blue node was found in 14 of 154 patients (9.1%). Eight of these 14 patients had separate blue-only nodes and hot-only nodes (so-called sequential mismatch). Four patients had SLNs identified by blue dye only, whereas 2 patients had SLNs localized solely by radioisotope labeling. On the other hand, metastatic disease was identified in SLNs of 40 of 154 patients (26.0%). A number of positive SLNs were 55 in these 40 patients, where 34 nodes (61.8%) were blue and hot, 9 were blue-only and 12 were hot-only. Among these 40 patients, 30 patients (75.0%) had blue and hot positive SLN. Four patients had blue-only positive SLN and 4 patients had hot-only positive SLN. Two patients had separate blue-only positive SLN and hot-only positive SLN. The SLN was the only positive node in 24 of the 41 positive SLN mapping (60%). Consequently, the false-negative rates were 9.8% (4/41) for peritumoral injection and 9.8% (4/41) for subareolar injection. There were no significant differences between peritumoral and subareolar injection. However, both injection methods complemented each other, thereby decreasing the false-negative rate to 0%. It is important to note that metastatic disease was identified by peritumoral injection in 4 patients in which the SLN was hot-only. At a median follow-up of 10.5 months (range, 2-22 months), there were no axillary recurrences in any of the 155 patients.
 Conclusions. Subareolar injection may not always identify the same SLN as peritumoral injection. Subareolar injection of blue dye and peritumoral injection of radioisotope improves the identification rate of the SLN and decrease the false-negative rate of SLN biopsy. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1022.

Sentinel lymph node biopsy after neoadjuvant chemotherapy is accurate in breast cancer patients with a clinically negative axillary nodal status at presentation.

Abstract Abstract #1020 Background: In breast cancer, neoadjuvant chemotherapy (NAC) is widely used in order to enable a conservative surgery. In patients treated with NAC, the use of sentinel lymph node (SLN) biopsy, which is a good predictor of the axillary nodal status in previously untreated patients, is still discussed. The aim of our study was to determine clinicopathological factors that may influence the accuracy of SLN biopsy after NAC.
 Patients and methods : Between March 2001 and December 2006, 129 patients with infiltrating breast carcinoma were studied prospectively. Preoperatively, all of them underwent NAC. At surgery, SLN biopsy followed by axillary lymph node (ALN) dissection was performed. Lymphatic mapping was done using the isotope method.
 Results : The SLN identification rate was 93.8% (121/129). Fifty-six out of the 121 sucessfully mapped patients had positive ALN. Eight out of these 56 patients had tumor-free SLN (false-negative rate of 14.3%). The false-negative rate was correlated with larger tumor size (T1-T2 versus T3; p=0.045) and positive clinical nodal status (N0 versus N1-N2; p=0.003) before NAC. In particular, the false-negative rate was 0% (0/29) in N0 patients and 29.6% (8/27) in N1-N2 patients. Clinical and pathological responses to NAC did not influence the accuracy of SLN biopsy.
 Conclusion : Our results show that clinical nodal status is the main clinicopathological factor influencing the false-negative rate of SLN biopsy after NAC for breast cancer. SLN biopsy after NAC can predict the ALN status with a high accuracy in patients who are clinically lymph node negative at presentation. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1020.

Sentinel lymph node biopsy after neoadjuvant chemotherapy in inflammatory breast cancer

Background Sentinel lymph node biopsy (SLNB) demonstrates promising results as an accurate alternative to axillary lymph node dissection in patients with locally advanced breast cancer after neoadjuvant chemotherapy (NAC). However and in the view of the insufficient data on women with inflammatory breast cancer (IBC), SLNB is not recommended in this situation. The current study assessed identification and false-negative rates of SLNB after NAC for patients with IBC. Methods Between 2006 and 2009, twenty consecutive patients with clinically negative nodes after NAC for IBC (T4d) and who underwent SLNB and axillary lymph node dissection (levels I and II) by the same operator were assessed. Intraoperative Sentinel lymph node biopsy was performed with patent blue dye injections. Results The SLN could be identified in 16 of 20 patients (identification rate, 80%), the median of SLN removed per patient was 2 (range 1–3); nine (56%) had positive SLNB, and in 2 of those 9 patients (22%), the SLN was the only positive node with otherwise negative axillary nodes. Two (18%) patients' SLNB were false negative. Conclusions The SLN identification and false-negative rates after NAC for IBC were unacceptably high and based on the current findings, SLNB without systematic axillary lymph node dissection is unsuitable in this patient population.

Comparison of outcome and recurrence-free survival after sentinel lymph node biopsy and lymphadenectomy in vulvar cancer

Objectives Lymph node status is an important prognostic factor in patients with squamous cell carcinoma (SCC) of the vulva. Complete inguinofemoral lymph node dissection (ILND) is accompanied by a high morbidity. Sentinel lymph node biopsy (SLNB) was established for less invasive lymph node (LN) staging. The aim of this study was to evaluate safety of SLNB in terms of accuracy and outcome in a clinical routine setting. Methods We retrospectively reviewed the data of patients who underwent SLNB and/or ILND for vulvar SCC in the years 1990–2007. Clinical follow-up was evaluated for histological nodal-negative patients with tumor stage T1 or T2. The false negative rate of SLNB was determined in patients who underwent both SLNB and ILND. Results Preoperative sentinel lymph node (SLN) visualization by scintigraphy was successful in 95% of all patients. SLNB was false negative in 1/45 inguinae (2.2%). All SLN were detected intraoperatively. During the follow-up period (median 24 months for SLNB and 111 months for ILND), no groin recurrences in initially nodal negative patients occurred ( n = 34, 59 inguinae). Transient lymph edema occurred in 7/18 patients after ILND (39%) and 2/16 patients (13%) after SLNB. No persistent edemas were found after SLNB and ILND. Conclusion According to our experience SLNB is feasible and accurately predicts LN status of vulvar SCC under clinical routine conditions. SLNB in vulvar cancer seems to be a safe alternative to ILND in order to reduce morbidity of surgical treatment.

Sentinel lymph node biopsy (SLNB) improves survival among SEER patients with melanoma

9005 Background: SLNB provides prognostic information. Its therapeutic impact is unclear. In a randomized trial of patients 18–75 years old with intermediate risk (INT) primary melanomas (1.2–3.5 mm in thickness and at least level III), Morton et al found no significant advantage in melanoma-specific survival (MSS) for those randomized to SLNB. However, the trial was underpowered. To validate these results in a large dataset, we examined survival in similar patients from SEER (1998–2002). We also did an analysis of patients with 0.75–1.2 mm melanomas (THIN). Methods: SEER patients with and without a SLNB were matched using 7 established prognostic factors and diagnosis year as well as a propensity score. Kaplan-Meier curves were used to estimate 5-year rates (MMS and OS). Paired survival times were compared using the Prentice-Wilcoxon test. Results: SLNB rates (1998–2002) were 71% and 43% among SEER patients with INT (n=2309) and THIN (n=2634) melanomas. The match resulted in 674 INT and 1126 THIN pairs. ...

Quality control: Surgical management of breast cancer—Opportunities and challenges

6521 Background: Intermountain Healthcare is a system of 9 major community hospitals based in Salt Lake City, Utah. The system has a long history of quality improvement and previously has standardized the use of breast preservation and the surgical management of ductal carcinoma in situ (DCIS). This project was undertaken to standardize evaluation of the axilla; specifically the incorporation and utilization of sentinel lymph node biopsy as the standard of care. Methods: Baseline data for sentinel node evaluation was obtained from 9 hospitals showing substantial variation between facilities and among surgeons. A physician-based surgical quality improvement team with system wide representation defined a 75% sentinel node biopsy rate as a minimally achievable goal. This allowed for legitimate omissions of sentinel node evaluation in a minority of patients. Processes put in place to increase compliance included: improved infrastructure, physician mentoring and increased accountability. The project was presented at each facility and surgeons were provided with data on their personal performance. Results were confirmed by individual chart review on a quarterly basis. Results: Sentinel node utilization was tracked in 265 patients treated by 67 surgeons from January 1, 2007 to June 30, 2007. Utilization increased from 69.1% to 82.6% system wide and in one facility increased from 39.1% to 90.9%. Utilization of sentinel node evaluation increased the axillary evaluation of patients with DCIS; an unexpected consequence of this project. Conclusions: Variation in surgical management can be decreased in a large hospital system through validated organizational processes. This process requires constant monitoring to assure gains are maintained and other quality indicators are not adversely affected. No significant financial relationships to disclose.

Intraoperative immunohistochemistry staining of sentinel nodes in breast cancer: Clinical and economical implications

The study aimed to evaluate intraoperative immunohistochemistry (IHC) staining of sentinel nodes in primary breast cancer surgery. We analysed retrospectively 1209 consecutive sentinel node procedures and compared the rate of late positive metastases in sentinel node biopsy (SNB) and the duration of the surgical procedures before ( n = 706) and after ( n = 503) introducing intraoperative IHC on frozen section. We also did a cost analysis. Intraoperative IHC staining led to a lowering of the late positive SNB rate. Introducing IHC gave a decrease in the late positive rate from 93 to 52% ( p < 0.0001) for isolated tumour cell metastasis, from 56 to 36.4% ( p < 0.02) for micrometastasis, and from 16 to 5% ( p < 0.01) for macrometastasis. The surgical procedures were slightly prolonged for lumpectomies but not for mastectomies after introducing intraoperative IHC staining. The cost analysis showed an overall cost saving of approximately 40%. In conclusion, intraoperative IHC staining of the SNB lowered the late positive rate and gave an overall cost saving.

Preoperative lymphscintigraphy did not improve the success rate of sentinel node biopsy in breast cancer patients

Preoperative lymphscintigraphy did not improve the success rate of sentinel node biopsy in breast cancer patients

Disparities and Trends in Sentinel Lymph Node Biopsy Among Early-Stage Breast Cancer Patients (1998-2005)

Sentinel lymph node biopsy (SLNB), an acceptable alternative to axillary lymph node dissection for staging patients with breast cancer, was introduced to clinical practice in the late 1990s. We assessed demographic, clinical, and facility-related factors associated with SLNB in women with early-stage breast cancer and evaluated trends in these factors over time. Data on early-stage breast cancers (T1a, T1b, T1c, and T2N0) diagnosed between January 1, 1998, and December 31, 2005, were extracted from the National Cancer Database, a hospital-based registry. Patient demographics, tumor stage, type of lymph node surgery, type of breast cancer surgery, health insurance, treatment facility type, and area-level education and income variables were collected. Multivariable logistic regression analyses were performed to assess predictive factors associated with SLNB, temporal differences in factors associated with SLNB, and differences in rates of SLNB by facility type, race/ethnicity, and type of health insurance over time. The total analytic study population included 490,899 women. The use of SLNB increased from 26.8% in 1998 to 65.5% in 2005. Factors associated with lower likelihood of SLNB over the study period included being older (odds ratio [OR] = 0.80, 95% confidence interval [CI] = 0.78 to 0.92 for those aged 72 or older compared with those aged 51 or younger), being of racial/ethnic minority (OR = 0.76, 95% CI = 0.74 to 0.78 for African Americans compared with whites), having no health insurance (OR = 0.77, 95% CI = 0.73 to 0.80 for uninsured compared with having private insurance), having certain government insurance plans (for Medicaid, OR = 0.81, 95% CI = 0.78 to 0.84, and for Medicare at age <65 years, OR = 0.83, 95% CI = 0.80 to 0.87, both compared with private insurance), residing in zip codes with lower proportion of high school graduates (OR = 0.88, 95% CI = 0.86 to 0.89) or with lower median income (OR = 0.79, 95% CI = 0.77 to 0.81), and receiving treatment in facility types other than a teaching or research hospital (for community hospital, OR = 0.84, 95% CI = 0.82 to 0.86; for community cancer center, OR = 0.86, 95% CI = 0.84 to 0.87). The associations with insurance status and sociodemographic characteristics were more pronounced in 2005 than in 1998. For example, the adjusted annual rates of SLNB in 1998 were 0.29 in whites, 0.26 in African Americans, and 0.35 in Hispanics; in 2005 the respective rates were 0.70, 0.64, and 0.67. Although use of SLNB increased from 1998 to 2005, disparities persisted in receipt of SLNB that are based on nonclinical factors, including sociodemographic characteristics and insurance status.

How Safe Is Sentinel Lymph Node Biopsy in Patients With Vulvar Cancer?

How Safe Is Sentinel Lymph Node Biopsy in Patients With Vulvar Cancer?

Subareolar blue dye only injection sentinel lymph node biopsy could reduce the numbers of standard axillary lymph node dissection in environments without access to nuclear medicine

The gold standard of axillary sentinel lymph node biopsy (SLNB) in breast cancer is the combination of radioactive colloid and blue dye injection. Worldwide, numerous hospitals without access to radioactive tracers still perform a routine complete axillary lymph node dissection (ALND). We retrospectively analyzed the false negative rate and identification rate of SLNB with injection of blue dye in the absence of radioactive colloid and compared the subareolar (SA) and the peritumoral (PT) injection. Two hundred and fourteen patients with clinically node negative unifocal breast cancer of up to 3 cm in size who underwent SLNB followed by ALND were included. Patent Blue V was injected at the SA site in 120 patients or at the PT site in 94 patients. Thirty-seven (31%) patients in the SA group and 28 (29.8%) in the PT group were node-positive by ALND. The mean number of SLNs identified was 3.1 in the SA group and 1.6 in the PT group. The SLN identification rate was 91.7% for the SA group and 80.9% for the PT group (P = 0.017). The false negative rate was 3.6% in the SA group and 11.8% in the PT group (P = 0.032). Our study shows an acceptable low false negative rate for the SA blue dye only injection and confirms the higher identification rate of SA versus PT localisation. This technique could have spared 67.5% (81 out of 120) of our patients the ALND and could replace ALND of early breast cancer patients in environments without access to nuclear medicine.

Sentinel Node Positivity Rates With and Without Frozen Section for Breast Cancer

Sentinel lymph node biopsy (SLNB) is used to detect breast cancer axillary metastases. Some surgeons send the sentinel lymph node (SLN) for intraoperative frozen section (FS) to minimize delayed axillary dissections. There has been concern that FS may discard nodal tissue and thus underdiagnose small metastases. This study examines whether evaluation of SLN by FS increases the false-negative rate of SLNB. A retrospective analysis of SLNB from 659 patients was conducted to determine the frequency of node positivity among SLNB subjected to both FS and permanent section (PS) versus PS alone. Statistical analysis was performed by the chi(2) square test, and a logistic regression model was applied to estimate the effect of final node positivity between the two groups. FS was performed in 327 patients and PS was performed in all 659 patients. Among patients undergoing both FS and PS (n = 327), the final node positivity rate was 33.0% compared with 19.6% among patients undergoing PS alone (n = 332). After adjustment for patient age, tumor diameter, grade, and hormone receptor status in a multivariate logistic regression model, there remained an increased likelihood of final node positivity for patients undergoing both procedures relative to PS alone (adjusted odds ratio, 2.1; 95% confidence interval, 1.3-3.6; P = .005). There was a higher rate of SLN positivity in specimens evaluated by both FS and PS. Therefore, evaluating SLN by FS does not underdiagnose small metastases nor produce a higher false-negative rate. Intraoperative FS offers the advantage of less delayed axillary dissections.

Prognostic value of sentinel node biopsy in 327 prospective melanoma patients from a single institution

Aim To confirm the accuracy of sentinel node biopsy (SNB) procedure and its morbidity, and to investigate predictive factors for SN status and prognostic factors for disease-free survival (DFS) and disease-specific survival (DSS). Materials and methods Between October 1997 and December 2004, 327 consecutive patients in one centre with clinically node-negative primary skin melanoma underwent an SNB by the triple technique, i.e. lymphoscintigraphy, blue-dye and gamma-probe. Multivariate logistic regression analyses as well as the Kaplan–Meier were performed. Results Twenty-three percent of the patients had at least one metastatic SN, which was significantly associated with Breslow thickness ( p < 0.001). The success rate of SNB was 99.1% and its morbidity was 7.6%. With a median follow-up of 33 months, the 5-year DFS/DSS were 43%/49% for patients with positive SN and 83.5%/87.4% for patients with negative SN, respectively. The false-negative rate of SNB was 8.6% and sensitivity 91.4%. On multivariate analysis, DFS was significantly worsened by Breslow thickness (RR = 5.6, p < 0.001), positive SN (RR = 5.0, p < 0.001) and male sex (RR = 2.9, p = 0.001). The presence of a metastatic SN (RR = 8.4, p < 0.001), male sex (RR = 6.1, p < 0.001), Breslow thickness (RR = 3.2, p = 0.013) and ulceration (RR = 2.6, p = 0.015) were significantly associated with a poorer DSS. Conclusion SNB is a reliable procedure with high sensitivity (91.4%) and low morbidity. Breslow thickness was the only statistically significant parameter predictive of SN status. DFS was worsened in decreasing order by Breslow thickness, metastatic SN and male gender. Similarly DSS was significantly worsened by a metastatic SN, male gender, Breslow thickness and ulceration. These data reinforce the SN status as a powerful staging procedure.

FACTORS AFFECTING FALSE‐NEGATIVE BREAST SENTINEL NODE BIOPSY IN CHINESE PATIENTS*

The objective of the research was to validate our results on sentinel lymph node biopsy (SLNB) and to determine factors affecting false-negative (FN) rates of SLNB in Chinese patients with invasive breast cancers. A retrospective study of patients with clinically node-negative invasive breast cancer was carried out from May 1999 to April 2006. A combination of radioisotope (99m)technetium(Tc)-albumin sulfur colloid and Patent Blue V dye was used to identify the sentinel lymph node. Sentinel lymph node biopsy was followed by standard level I and II axillary dissection in all patients. Various clinicopathologic variables were analysed to determine factors associated with FN SLNB. Three hundred and sixty-five Chinese patients received SLNB consecutively during the study period. Seventy-eight patients with neoadjuvant chemotherapy and 56 patients with in situ carcinoma were excluded. A total of 231 patients were studied. Sentinel lymph nodes were identified in 221 patients (95.7%). There were 10 FN, resulting in a FN rate of 12.5% and accuracy rate of 95.5%. Only the number of sentinel lymph node harvested was found to be a significant factor affecting FN rates on univariate (P < 0.009) and multivariate logistic regression (odds ratio: 2.65; 95% confidence interval: 2.57-2.73; P < 0.000). In Chinese women, after this retrospective analysis of available findings, at least should sentinel nodes should be removed to reduce risk of false negativity.